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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201037
Report Date: 02/24/2023
Date Signed: 02/24/2023 03:16:07 PM


Document Has Been Signed on 02/24/2023 03:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:GREEN PASTURES RESIDENCES LLC - OAKMONT MANORFACILITY NUMBER:
079201037
ADMINISTRATOR:ENRIQUEZ, STEPHANIE NARESFACILITY TYPE:
740
ADDRESS:1408 OAKMONT PLTELEPHONE:
(925) 858-1870
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 3DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Reymund Tulabot, CaregiverTIME COMPLETED:
03:30 PM
NARRATIVE
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On 2/24/2023 at 11:35AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Reymund Tulabot, Caregiver and explained the purpose of the visit. Herminia Quismorio, Administrator, arrived at 11:53AM.

Upon entry, LPA's temperature was checked. LPA observed screening station and COVID-19 signs were posted on the front door. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, back yard, kitchen, and garage. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 141.8 degrees Fahrenheit. Fire extinguisher last purchased 9/5/2020. LPA observed a minimum of 7-day non-perishables and 2-day perishables foods.

During record review, LPA observed visitors sign-in log. LPA observed facility has a copy of the infection control plan on file. LPA observed food and paper supplies are sufficient.

Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: GREEN PASTURES RESIDENCES LLC - OAKMONT MANOR
FACILITY NUMBER: 079201037
VISIT DATE: 02/24/2023
NARRATIVE
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Continued from LIC809.

LPA request the following documents to be submitted to CCLD by 3/3/2023.
  • Personnel record (LIC500)
  • Facility Roster (LIC9020)
  • Emergency disaster plan (LIC610E)
  • Designation of Facility Responsibility (LIC308)
  • Documents to change Administrator

The following deficiencies were observed:
  • At 11:40AM, LPA observed S1, S2, and S3 were not associated to the facility.
  • At 11:44PM, LPA observed fire extinguisher last purchased on 9/5/2020.
  • At 11:45AM, LPA observed Clorox, Comet, and Lysol disinfectant spray in unlocked kitchen cabinet underneath sink.
  • At 11:50AM, LPA observed two (2) rooms built inside of garage.
  • At 11:55AM, LPA observed wooden bed frame, 5 chairs, a wooden night stand, and a bath seat located on right side of house.
  • At 12:05PM, LPA observed residents in bedrooms #1 and #2, which are for ambulatory residents only. Per fire clearance non-ambulatory in bedroom #4 and all other bedrooms are for ambulatory residents only.
  • At 12:10PM, LPA observed water temperature in residents' shared bathroom at 141.8 degrees F.
  • At 12:15PM, LPA observed that R1 did not have an order for a hospital bed.
  • At 12:20PM, LPA observed that S1 was not able to obtain personnel files due to files being locked in room in garage.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 02/24/2023 03:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: GREEN PASTURES RESIDENCES LLC - OAKMONT MANOR
FACILITY NUMBER: 079201037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having S1, S2, and S3 associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2023
Plan of Correction
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Licensee agreed to submit LIC9182 and a copy of Identifications for S1, S2, and S3 to CCLD by POC date. LIC9182's and identifications were submitted during visit. Deficiency cleared during visit.
Type A
Section Cited
CCR
87309(a)
87309 Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having disinfectants and cleaners inaccessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2023
Plan of Correction
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Caregivers removed cleaners and disinfectants and locked them in away making them inaccessible to residents. Deficiency cleared during visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 02/24/2023 03:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: GREEN PASTURES RESIDENCES LLC - OAKMONT MANOR
FACILITY NUMBER: 079201037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(2)
87303 Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having water temperature between 105 - 120 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2023
Plan of Correction
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Licensee agreed to adjust water temperature between 105 -120 degrees F and submit a photo of new water temperature to CCLD by POC date.
Type A
Section Cited
CCR
87202(a)(1)
87202 Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.

(1) Nonambulatory persons.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having non-ambulatory residents in ambulatory only bedrooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/25/2023
Plan of Correction
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Licensee agreed to submit a written plan on what actions facility will take in to place non-ambulatory residents in proper rooms and submit plan to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
LIC809 (FAS) - (06/04)
Page: 5 of 7


Document Has Been Signed on 02/24/2023 03:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: GREEN PASTURES RESIDENCES LLC - OAKMONT MANOR
FACILITY NUMBER: 079201037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
87203 Fire Safety

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in the fire extinguisher checked annually which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2023
Plan of Correction
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Licensee agreed to purchase a new fire extinguisher or have it checked by the fire department and submit photo with receipt or updated card from fire department to CCLD by POC date.
Type B
Section Cited
CCR
87305(b)
87305 Alterations to Existing Building or New Facilities

(b) The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having submitted a fire clearance and updated facility sketch to CCLD which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2023
Plan of Correction
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Licensee agreed to submit an updated facility sketch and LIC200 to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 02/24/2023 03:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: GREEN PASTURES RESIDENCES LLC - OAKMONT MANOR
FACILITY NUMBER: 079201037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)(1)
87412 Personnel Records
(g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.
(1) The licensee shall be permitted to retain such records in a central administrative location provided that they are readily available to the licensing agency at the facility as specified in Section 87412(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in having personnel records accessible for CCL which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2023
Plan of Correction
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Licensee agrees to review regulation 87412 and submit self-certification that facility will abide by regulation going forwarded to CCLD by POC date.
Type B
Section Cited
CCR
87303(d)(6)
87307 Personal Accommodations and Services
d) The following space and safety provisions shall apply to all facilities:
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in having outdoor passage way on right side of house clear of debris which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2023
Plan of Correction
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Licensee agreed to remove all debris and submit photo to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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